Vermont Health Commissioner supports changing aggressive pain management rules

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BURLINGTON >> In an effort to reduce overprescribing of opioid pain relievers, Vermont Health Commissioner Harry Chen, MD and dozens of public health officials, health care organizations, medical experts, and consumer advocacy groups from across the country today petitioned the Joint Commission, an agency that accredits health care organizations, and to the federal agency that oversees Medicare. Signers are requesting changes to pain management requirements they believe foster dangerous prescribing practices.

"Overprescribing opioid painkillers is a root cause of the deadly crisis of addiction we are now facing, not only here in Vermont but across the country," said Dr. Chen. "To reverse this trend, we must understand the cultural context that led well-meaning prescribers to this point. Aggressive and misleading marketing by drug manufacturers, and pressure by those bodies that accredit, oversee and reimburse health care organizations and providers to treat pain as the 'fifth vital sign' made for a system that encourages unwarranted prescribing."

Over the past 20 years, prescriptions for opioid painkillers have soared in the U.S., leading to an epidemic of opioid addiction, rising heroin use and a record high rate of overdose deaths. Opioid prescribing increased in response to a multifaceted campaign, which called for pain to be treated as if it was a vital sign, a measure of essential bodily function, which includes temperature, breathing rate, blood pressure and pulse. In 2001, the Joint Commission introduced pain management standards requiring health care organizations to ask every patient about pain, leading to use of pain patient scales and hospital policies requiring aggressive pain management. In their letter to the Joint Commission, petitioners wrote that mandatory pain assessment in all patients and in all medical settings is "unwarranted and can lead to overtreatment and overuse of opioid analgesics". A recent study found that physicians prescribed opioids, often in high doses, in more than half of 1.14 million nonsurgical hospital admissions.

"As an emergency physician I saw first hand the effect of these pressures," said Dr. Chen. "For example, it was expected of nurses to wake patients up to evaluate their pain, and request more pain medication 'if needed', and hospitals led so-called quality improvement efforts to more aggressively treat pain. As physicians, we are duty-bound to relieve pain and suffering, but as a result of the overreliance on opioid painkillers we are in fact causing undue pain and suffering."

The petition sent to the Centers for Medicare and Medicaid Services (CMS) calls for removal of the pain questions from HCAHPS, the agency's patient satisfaction survey used for determining hospital reimbursement rates. In their letter to CMS, petitioners wrote "Aggressive management of pain should not be equated with quality healthcare as it can result in unhelpful and unsafe treatment, the end point of which is often the inappropriate provision of opioids." The petitioners believe that linking hospital reimbursement to patient satisfaction with pain treatment results in overprescribing of opioids.


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